Codeine! The analgesic of choice for head injury patients for junior house staff those many moons ago! It wasn’t really a choice, we weren’t allow to use morphine because it was dangerous!
But what do we know now….?
Codeine is a pro-drug that gets broken down to morphine. So all those years ago we were delivering low dose morphine and probably constipating patients without much pain relief!
As I have written before, codeine gets broken down to morphine by an enzyme in the liver (primarily), cytochrome P450 2D6. This enzyme is lacking in children, and many guidelines are recommending that we don’t use codeine in children! So much so, the WHO guidelines for persisting pain in children (in multiple languages) have moved to a two step ladder. Essentially, paracetamol (acetaminophen) and morphine!
Despite the FDA issuing warnings about the use of codeine in children this paper by Dr Kaiser and colleagues shows that its prescribing still very common in the US! Clearly some educating to be done here. Maybe even some regulating!
But what is the impact of moving to a “Two step” ladder in other parts of the world where in many cases codeine, tramadol or dihydrocodeine may be the only opioid available with no access to morphine. I have not included Hydrodocodone here as the USA is really the only country to use it. That is why the statistics that we consume 99% of the world’s hydrocodone is meaningless. Very few other countries allow it!
We will discuss the step II opioids and their impact and role in palliative care during #Hpmglobal chat Monday April 28th. 12 noon GMT (7 am in Madison, 1 pm in London and 10 pm in Sydney. Other times available here).
Among the questions…….
What is the impact of rescheduling tramadol?
What is codeine were not available?